palliative care clinic patient referral form

ACCT #:
Patient Name:
GENDER
DOB:
PALLIATIVE CARE CLINIC
PATIENT REFERRAL FORM
HC #:
UNIT #:
BETTY AND BUSTER LOCKWOOD CANCER CENTRE
THE CARLO FIDANI PEEL REGIONAL CANCER CENTRE
150 Sherway Drive W. Toronto. M9C 1A5
Telephone: 416-259-7580 X5745 Fax: 416-521-4104
2200 Eglinton Avenue West, Mississauga. L5M 2H6
Telephone: 905-813-1100 X5143 Fax: 905-813-4024
Street
Apt/Unit #
City - Province
Home Phone:
Other Phone:
Postal Code
Does the patient speak English?
Yes
Alternate Contact
Other Phone:
Home Phone:
Person to Contact with Appt.:
Patient
Version Code
No
Family MD
Alternate
Primary Diagnosis:
Phone:
Other Medical Diagnosis:
Fax:
No Family MD
Urgency (see reverse side)
level 1
level 2
Palliative Care Referral
level 3
CVH only
Patient Informed of Referral
Palliative Performance Scale (10-100)
(see reverse side)
Advance Practice Nurse Referral (APN)
* Direct communication required
Same Day
Next Oncology Visit
APN Scheduled Visit
Specific Concerns:
Reason for Referral:
Pain and Symptom Management
Psychosocial Support
End of Life Care
Information required with external referral:
Medications and Doses
Consultations and Recent Clinical Notes
Referring MD
Phone:
Laboratory and Diagnostic Imaging
Fax:
Date:
For Office Use Only
Appt Date:___________________________
Appointment Given To:
Date received:
Patient
Time: _________________________
Other: ____________________________
MD: ____________________________________
Date Notified: _____________________________
Staff Signature:
PALLIATIVE CARE CLINIC - PATIENT REFERRAL FORM
9822 D HR (April/2016) Page 1 of 2
MD Signature:
Physician #
Information for referring physicians
1. Only patients with cancer as their primary diagnosis will be seen in the Palliative Care Clinic.
2. Referrals must be accompanied by appropriate clinical information including consultations and clinical
notes, laboratory and diagnostic information and medications with dosages.
3. Referrals are reviewed and appointments scheduled based on the stated urgency (see below), the Palliative
Performance Scale (see below) and the patient's residence within the catchment area of the Peel Regional
Cancer Centre.
4. The patient will be seen and assessed by a nurse and palliative care physician. A care plan will be
developed based on the patient's current needs. The assessment and recommendations will be reviewed
with the patient and family and will be provided to the referring physician and the family physician.
5. Follow-up care may be designated to the referring physician, the family physician or to the Palliative Care
Clinic. Follow-up care may also be shared between the primary care physician and the Palliative Care
Clinic. The Palliative Care Clinic does not automatically assume primary care for all referred patients.
Urgency Symptoms are best rated using 10 point scale (0 none, 10 worst) such as the Edmonton Symptom Assessment Scale.
Severe symptoms (7-10/10 on analog scale); severe psychosocial distress or dysfunction; prognosis less than 1 month
Level 2:
Moderate symptoms (4-6/10); moderate psychosocial difficulties; prognosis 1-3 months
Level 3:
Noncurative disease, No or mild symptoms, prognosis 3-12 months
9822 D HR (April/2016) Page 2 of 2
Level 1:
PALLIATIVE CARE CLINIC - PATIENT REFERRAL FORM